8 ways Trump hurt Obamacare in his first year

Within hours of being sworn in last year, President Trump signed an executive order aimed at minimizing Obamacare's financial burden on the nation. It was his first attempt to dismantle his predecessor's landmark health reform law.

But it was certainly not his last. While Republicans in Congress failed repeatedly to repeal and replace the Affordable Care Act in 2017, Trump did take some major steps to weaken it.

Limited support for open enrollment: The administration swiftly halted up to $5 million in Obamacare advertising in the final days ahead of the open enrollment deadline for 2017 coverage. A spokesman said at the time "We aren't going to continue spending millions of taxpayers' dollars promoting a failed government program."

Sign ups fell by half a million for last year.

The administration made even bigger changes to Obamacare's 2018 open enrollment season. It cut in half the time consumers had to sign up on the federal exchange, giving them only six weeks instead of three months. Officials also slashed the advertising budget by 90% and reduced federal support for counselors who help people navigate the enrollment process by more than 40%.

Still, 8.7 million people signed up for coverage in the 39 states on the federal exchange, only half a million fewer than the prior year. Many experts had expected a much larger contraction.

Killed the cost-sharing subsidies: In October, the administration stopped paying the cost-sharing subsidies that reimburse insurers for reducing the deductibles and out-of-pocket costs of roughly 6 million lower-income Obamacare enrollees. The funding had been the subject of a court battle between House Republicans and the Obama administration, with GOP lawmakers arguing the payments were illegal because Congress never appropriated the money.

Though insurers had warned earlier in the year that ending the cost-sharing subsidy funding could bring down Obamacare, the reaction was largely muted. That's because most carriers had already hiked premiums substantially for 2018 in anticipation of the move.

In an unusual twist, Trump's move actually made Obamacare more affordable for many consumers. They benefited from higher premium subsidies that allowed them to buy some 2018 plans on the exchange for less than they were currently paying. However, middle class Americans who don't qualify for premium subsidies had to cope with the full rate hikes.

Eliminated the individual mandate: Congress did manage to effectively repeal the individual mandate, starting in 2019, as part of its tax overhaul legislation. Trump signed it into law last month.

One of Obamacare's least popular provisions, the mandate requires nearly all Americans to have health insurance or pay a penalty. While the mandate's effectiveness is a matter of debate, many experts worry its elimination may prompt insurers to drop out and premiums to spike if fewer young and healthy consumers enroll on the exchanges. The Congressional Budget Office predicts that 13 million more people will be uninsured by 2027, though it is reviewing its methodology.

Earlier in the year, the administration took its own step to blunt the impact of the individual mandate. The Internal Revenue Service had been set to start rejecting tax returns last year that failed to indicate whether filers had health insurance, obtained an exemption or paid a penalty. But soon after Trump issued his January executive order, the agency quietly reversed that decision.

Gave states more control over Medicaid programs: States can now impose work requirements on Medicaid recipients for the first time. The administration released a guidance this month outlining what states need to do to mandate that certain enrollees work, volunteer or participate in other "community engagement activities" to qualify for benefits.

The Centers for Medicare & Medicaid Services is also encouraging states to submit waivers making additional changes to their Medicaid programs. States are requesting permission to charge recipients premiums, limit the time they can receive benefits, test them for drugs and lock them out if they fail to keep up with payments or paperwork.

"Medicaid needs to be more flexible so that states can best address the needs of this population," said Seema Verma, the agency's administrator.

Trump administration and state officials say these measures will help people gain independence and prepare them to purchase health insurance on their own. Critics, however, argue states are putting additional hurdles in place to winnow down their rolls.

Proposed allowing small businesses to buy health insurance together: The administration unveiled a proposed rule earlier this month that would make it easier for small businesses -- and some self-employed folks -- to band together and buy health insurance.

The proposed regulation stems from an executive order Trump issued in October. It would allow small firms to form association health plansbased on their location or industry. Sole proprietors would also be eligible to join the plans, which would ideally be able to use their scale to secure less expensive coverage much like large employer plans do.

Plans would be able to offer coverage across state lines, a longtime Republican goal and one of Trump's campaign pledges.

The associations could provide an attractive alternative to Obamacare for some people, especially younger and healthier consumers. But it could also damage the Obamacare exchanges, leaving them with mostly older and sicker enrollees and driving up premiums.

Encouraged the sale of short-term health plans: Trump's October executive order also directed agencies to consider expanding the availability of short-term health insurance policies.

The Obama administration limited the duration of short-term health plans to no more than 90 days in order to make them less attractive. While the administration hasn't yet issued proposed rules, it is expected to lift the cap, enabling consumers to buy policies that would last just under a year.

Short-term plans don't have to adhere to Obamacare's regulations so consumers would have a wider array of options with lower monthly rates. But they can exclude those with pre-existing conditions or base rates on consumers' medical history. They can also offer skimpier benefits so policyholders may have to pay more out of pocket if they actually need care.

Also on tap, the executive order would expand employers' ability to give workers cash to buy coverage elsewhere under a system known as health reimbursement arrangements.

Weakened the contraceptive mandate: Employers may now have more leeway to withhold birth control coverage on religious grounds, undermining the controversial Obamacare mandate that requires contraceptives be covered with no co-pay.

A broad range of employers -- including nonprofits, private firms and privately traded companies -- would no longer be required to provide contraceptives if they have sincerely held religious beliefs. The same provision applies to organizations and small businesses that have objections "on the basis of moral conviction which is not based in any particular religious belief," according to the administration.

Until now, a fairly limited number of employers -- mainly churches and some other religious entities -- could get an exemption to the mandate. Some others, such as religious-based universities or hospitals, could seek accommodations so that they didn't have to provide coverage, but their workers could still get covered contraceptives that would be paid for by the insurer or the employer plan's administrator.

Tightened the rules for consumers seeking coverage, while loosening them for insurers: The administration also made it harder to sign up for insurance at other times. Those seeking coverage during special enrollment periods because of a job loss, divorce or other major life changes have to provide documentation proving their eligibility.

Also, consumers now must pay any back premiums they owe before signing up again.

Insurers had long sought to tighten the rules, arguing that people are gaming the system and enrolling only when they get sick. Consumer advocates were concerned that it will make it harder for those truly eligible to qualify.

Insurers, meanwhile, gained greater flexibility in the amount their policies would pay in each tier of coverage on the exchanges. A new "expanded bronze" plan option -- with higher deductibles and co-pays, but lower premiums -- debuted for 2018.

And the federal government pulled back on its reviews of whether insurers have enough doctors and hospitals in their networks. The Obama administration added this oversight after enrollees complained there were too few providers who accepted their plans.